|
INSERT TUNNELED CV CATH 36561
|
Professional
|
Both
|
$4,450.00
|
|
|
Service Code
|
CPT 36561
|
| Hospital Charge Code |
3014533
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,017.73 |
| Max. Negotiated Rate |
$4,227.50 |
| Rate for Payer: Aetna Commercial |
$4,227.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,827.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$4,227.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,017.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,670.00
|
| Rate for Payer: Health EOS Commercial |
$4,049.50
|
| Rate for Payer: HFN Commercial |
$4,227.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,100.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,100.97
|
| Rate for Payer: Multiplan Commercial |
$3,560.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,227.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,958.00
|
| Rate for Payer: Quartz Commercial |
$2,536.50
|
| Rate for Payer: The Alliance Commercial |
$2,225.00
|
| Rate for Payer: United Healthcare Medicaid |
$1,017.73
|
| Rate for Payer: WEA Trust Commercial |
$2,447.50
|
| Rate for Payer: WPS Commercial |
$3,296.12
|
|
|
INSOLE PEGASSIST MENS XLG PTQM4
|
Facility
|
IP
|
$229.00
|
|
| Hospital Charge Code |
2974301
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$112.21 |
| Max. Negotiated Rate |
$210.68 |
| Rate for Payer: Aetna Commercial |
$206.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.37
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$210.68
|
| Rate for Payer: Health EOS Commercial |
$203.81
|
| Rate for Payer: HFN Commercial |
$210.68
|
| Rate for Payer: Multiplan Commercial |
$183.20
|
| Rate for Payer: NAPHCARE Commercial |
$137.40
|
| Rate for Payer: Preferred Network Access Commercial |
$210.68
|
| Rate for Payer: Quartz Beloit One Network |
$112.21
|
| Rate for Payer: Quartz Commercial |
$137.40
|
| Rate for Payer: WEA Trust Commercial |
$125.95
|
| Rate for Payer: WPS Commercial |
$169.62
|
|
|
INSOLE PEGASSIST MENS XLG PTQM4
|
Facility
|
OP
|
$229.00
|
|
| Hospital Charge Code |
2974301
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.12 |
| Max. Negotiated Rate |
$916.00 |
| Rate for Payer: Aetna Commercial |
$206.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.94
|
| Rate for Payer: Aetna Managed Medicare |
$64.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$109.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.37
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$210.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.15
|
| Rate for Payer: Health EOS Commercial |
$203.81
|
| Rate for Payer: HFN Commercial |
$210.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.75
|
| Rate for Payer: Multiplan Commercial |
$183.20
|
| Rate for Payer: NAPHCARE Commercial |
$137.40
|
| Rate for Payer: Preferred Network Access Commercial |
$210.68
|
| Rate for Payer: Quartz Beloit One Network |
$112.21
|
| Rate for Payer: Quartz Commercial |
$148.85
|
| Rate for Payer: Quartz Medicare Advantage |
$137.40
|
| Rate for Payer: The Alliance Commercial |
$916.00
|
| Rate for Payer: WEA Trust Commercial |
$125.95
|
| Rate for Payer: WPS Commercial |
$169.62
|
|
|
INSTILLATION(S) OF THERAPEUTIC AGENT INTO RENAL PELVIS AND/OR URETER THROUGH ESTABLISHED NEPHROSTOMY, PYELOSTOMY OR URETEROSTOMY TUBE (EG, ANTICARCINOGENIC OR ANTIFUNGAL AGENT)
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 50391
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$244.28 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$244.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$244.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$244.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$244.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$244.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$244.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$908.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$244.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$244.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$244.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$244.28
|
| Rate for Payer: NAPHCARE Commercial |
$366.42
|
| Rate for Payer: Quartz Medicare Advantage |
$244.28
|
| Rate for Payer: The Alliance Commercial |
$977.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$244.28
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$244.28
|
|
|
INSTL THER AGENT RENAL PELVIS&/URETER VIA TUBE 50391
|
Professional
|
Both
|
$849.00
|
|
|
Service Code
|
CPT 50391
|
| Hospital Charge Code |
6174993
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$121.62 |
| Max. Negotiated Rate |
$806.55 |
| Rate for Payer: Aetna Commercial |
$806.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.14
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cigna Commercial |
$806.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$509.40
|
| Rate for Payer: Health EOS Commercial |
$772.59
|
| Rate for Payer: HFN Commercial |
$806.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$327.20
|
| Rate for Payer: Multiplan Commercial |
$679.20
|
| Rate for Payer: Preferred Network Access Commercial |
$806.55
|
| Rate for Payer: Quartz Beloit One Network |
$373.56
|
| Rate for Payer: Quartz Commercial |
$483.93
|
| Rate for Payer: The Alliance Commercial |
$424.50
|
| Rate for Payer: United Healthcare Medicaid |
$121.62
|
| Rate for Payer: WEA Trust Commercial |
$466.95
|
| Rate for Payer: WPS Commercial |
$628.85
|
|
|
INSTRUMENT MAGNET LARGE 20 X 16 DYNJMDL1
|
Facility
|
OP
|
$209.00
|
|
| Hospital Charge Code |
2963086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.52 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Aetna Managed Medicare |
$58.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$192.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.96
|
| Rate for Payer: Health EOS Commercial |
$186.01
|
| Rate for Payer: HFN Commercial |
$192.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.75
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: NAPHCARE Commercial |
$125.40
|
| Rate for Payer: Preferred Network Access Commercial |
$192.28
|
| Rate for Payer: Quartz Beloit One Network |
$102.41
|
| Rate for Payer: Quartz Commercial |
$135.85
|
| Rate for Payer: Quartz Medicare Advantage |
$125.40
|
| Rate for Payer: The Alliance Commercial |
$836.00
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
INSTRUMENT MAGNET LARGE 20 X 16 DYNJMDL1
|
Facility
|
IP
|
$209.00
|
|
| Hospital Charge Code |
2963086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.41 |
| Max. Negotiated Rate |
$192.28 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$192.28
|
| Rate for Payer: Health EOS Commercial |
$186.01
|
| Rate for Payer: HFN Commercial |
$192.28
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: NAPHCARE Commercial |
$125.40
|
| Rate for Payer: Preferred Network Access Commercial |
$192.28
|
| Rate for Payer: Quartz Beloit One Network |
$102.41
|
| Rate for Payer: Quartz Commercial |
$125.40
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
INSTRUMENT PACK EASYFUSE MID/HIND FOOT FFSP1530
|
Facility
|
IP
|
$3,074.00
|
|
| Hospital Charge Code |
6200963
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,506.26 |
| Max. Negotiated Rate |
$2,828.08 |
| Rate for Payer: Aetna Commercial |
$2,766.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,643.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,629.22
|
| Rate for Payer: Cash Price |
$922.20
|
| Rate for Payer: Cigna Commercial |
$2,828.08
|
| Rate for Payer: Health EOS Commercial |
$2,735.86
|
| Rate for Payer: HFN Commercial |
$2,828.08
|
| Rate for Payer: Multiplan Commercial |
$2,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,844.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,828.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,506.26
|
| Rate for Payer: Quartz Commercial |
$1,844.40
|
| Rate for Payer: WEA Trust Commercial |
$1,690.70
|
| Rate for Payer: WPS Commercial |
$2,276.91
|
|
|
INSTRUMENT PACK EASYFUSE MID/HIND FOOT FFSP1530
|
Facility
|
OP
|
$3,074.00
|
|
| Hospital Charge Code |
6200963
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$860.72 |
| Max. Negotiated Rate |
$12,296.00 |
| Rate for Payer: Aetna Commercial |
$2,766.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,643.64
|
| Rate for Payer: Aetna Managed Medicare |
$860.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,998.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,537.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,475.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,629.22
|
| Rate for Payer: Cash Price |
$922.20
|
| Rate for Payer: Cigna Commercial |
$2,828.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,720.21
|
| Rate for Payer: Health EOS Commercial |
$2,735.86
|
| Rate for Payer: HFN Commercial |
$2,828.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,305.50
|
| Rate for Payer: Multiplan Commercial |
$2,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,844.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,828.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,506.26
|
| Rate for Payer: Quartz Commercial |
$1,998.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,844.40
|
| Rate for Payer: The Alliance Commercial |
$12,296.00
|
| Rate for Payer: WEA Trust Commercial |
$1,690.70
|
| Rate for Payer: WPS Commercial |
$2,276.91
|
|
|
INSTRUMENT PACK WITH BLADE PROSTEP MIS STERILE 57S1MI07
|
Facility
|
IP
|
$3,171.00
|
|
| Hospital Charge Code |
6172006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,553.79 |
| Max. Negotiated Rate |
$2,917.32 |
| Rate for Payer: Aetna Commercial |
$2,853.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,680.63
|
| Rate for Payer: Cash Price |
$951.30
|
| Rate for Payer: Cigna Commercial |
$2,917.32
|
| Rate for Payer: Health EOS Commercial |
$2,822.19
|
| Rate for Payer: HFN Commercial |
$2,917.32
|
| Rate for Payer: Multiplan Commercial |
$2,536.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,902.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,917.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,553.79
|
| Rate for Payer: Quartz Commercial |
$1,902.60
|
| Rate for Payer: WEA Trust Commercial |
$1,744.05
|
| Rate for Payer: WPS Commercial |
$2,348.76
|
|
|
INSTRUMENT PACK WITH BLADE PROSTEP MIS STERILE 57S1MI07
|
Facility
|
OP
|
$3,171.00
|
|
| Hospital Charge Code |
6172006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$887.88 |
| Max. Negotiated Rate |
$12,684.00 |
| Rate for Payer: Aetna Commercial |
$2,853.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.06
|
| Rate for Payer: Aetna Managed Medicare |
$887.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,061.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,585.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,522.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,680.63
|
| Rate for Payer: Cash Price |
$951.30
|
| Rate for Payer: Cigna Commercial |
$2,917.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,774.49
|
| Rate for Payer: Health EOS Commercial |
$2,822.19
|
| Rate for Payer: HFN Commercial |
$2,917.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,378.25
|
| Rate for Payer: Multiplan Commercial |
$2,536.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,902.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,917.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,553.79
|
| Rate for Payer: Quartz Commercial |
$2,061.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,902.60
|
| Rate for Payer: The Alliance Commercial |
$12,684.00
|
| Rate for Payer: WEA Trust Commercial |
$1,744.05
|
| Rate for Payer: WPS Commercial |
$2,348.76
|
|
|
INSTRUMENTS DUAFIT SET A06 10401
|
Facility
|
IP
|
$3,947.00
|
|
| Hospital Charge Code |
6021650
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,934.03 |
| Max. Negotiated Rate |
$3,631.24 |
| Rate for Payer: Aetna Commercial |
$3,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.91
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,631.24
|
| Rate for Payer: Health EOS Commercial |
$3,512.83
|
| Rate for Payer: HFN Commercial |
$3,631.24
|
| Rate for Payer: Multiplan Commercial |
$3,157.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,934.03
|
| Rate for Payer: Quartz Commercial |
$2,368.20
|
| Rate for Payer: WEA Trust Commercial |
$2,170.85
|
| Rate for Payer: WPS Commercial |
$2,923.54
|
|
|
INSTRUMENTS DUAFIT SET A06 10401
|
Facility
|
OP
|
$3,947.00
|
|
| Hospital Charge Code |
6021650
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,105.16 |
| Max. Negotiated Rate |
$15,788.00 |
| Rate for Payer: Aetna Commercial |
$3,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,105.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,565.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,973.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,894.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.91
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,631.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,208.74
|
| Rate for Payer: Health EOS Commercial |
$3,512.83
|
| Rate for Payer: HFN Commercial |
$3,631.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,960.25
|
| Rate for Payer: Multiplan Commercial |
$3,157.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,934.03
|
| Rate for Payer: Quartz Commercial |
$2,565.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,368.20
|
| Rate for Payer: The Alliance Commercial |
$15,788.00
|
| Rate for Payer: WEA Trust Commercial |
$2,170.85
|
| Rate for Payer: WPS Commercial |
$2,923.54
|
|
|
INSTRUMENT SET CARTIVA 8MM DISPOSABLE MTK-08
|
Facility
|
IP
|
$3,903.00
|
|
| Hospital Charge Code |
5831679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,912.47 |
| Max. Negotiated Rate |
$3,590.76 |
| Rate for Payer: Aetna Commercial |
$3,512.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,356.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,068.59
|
| Rate for Payer: Cash Price |
$1,170.90
|
| Rate for Payer: Cigna Commercial |
$3,590.76
|
| Rate for Payer: Health EOS Commercial |
$3,473.67
|
| Rate for Payer: HFN Commercial |
$3,590.76
|
| Rate for Payer: Multiplan Commercial |
$3,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,341.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,590.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,912.47
|
| Rate for Payer: Quartz Commercial |
$2,341.80
|
| Rate for Payer: WEA Trust Commercial |
$2,146.65
|
| Rate for Payer: WPS Commercial |
$2,890.95
|
|
|
INSTRUMENT SET CARTIVA 8MM DISPOSABLE MTK-08
|
Facility
|
OP
|
$3,903.00
|
|
| Hospital Charge Code |
5831679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,092.84 |
| Max. Negotiated Rate |
$15,612.00 |
| Rate for Payer: Aetna Commercial |
$3,512.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,356.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,092.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,536.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,951.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,873.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,068.59
|
| Rate for Payer: Cash Price |
$1,170.90
|
| Rate for Payer: Cigna Commercial |
$3,590.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,184.12
|
| Rate for Payer: Health EOS Commercial |
$3,473.67
|
| Rate for Payer: HFN Commercial |
$3,590.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,927.25
|
| Rate for Payer: Multiplan Commercial |
$3,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,341.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,590.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,912.47
|
| Rate for Payer: Quartz Commercial |
$2,536.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,341.80
|
| Rate for Payer: The Alliance Commercial |
$15,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,146.65
|
| Rate for Payer: WPS Commercial |
$2,890.95
|
|
|
INSTRUMENTS OSTEOCHANDRAL FLAP REPAIR SINGLE SHOT (DISP) AR-4009S
|
Facility
|
IP
|
$2,997.00
|
|
| Hospital Charge Code |
5885644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,468.53 |
| Max. Negotiated Rate |
$2,757.24 |
| Rate for Payer: Aetna Commercial |
$2,697.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,577.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,588.41
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$2,757.24
|
| Rate for Payer: Health EOS Commercial |
$2,667.33
|
| Rate for Payer: HFN Commercial |
$2,757.24
|
| Rate for Payer: Multiplan Commercial |
$2,397.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,798.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,757.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,468.53
|
| Rate for Payer: Quartz Commercial |
$1,798.20
|
| Rate for Payer: WEA Trust Commercial |
$1,648.35
|
| Rate for Payer: WPS Commercial |
$2,219.88
|
|
|
INSTRUMENTS OSTEOCHANDRAL FLAP REPAIR SINGLE SHOT (DISP) AR-4009S
|
Facility
|
OP
|
$2,997.00
|
|
| Hospital Charge Code |
5885644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$839.16 |
| Max. Negotiated Rate |
$11,988.00 |
| Rate for Payer: Aetna Commercial |
$2,697.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,577.42
|
| Rate for Payer: Aetna Managed Medicare |
$839.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,948.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,498.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,438.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,588.41
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$2,757.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,677.12
|
| Rate for Payer: Health EOS Commercial |
$2,667.33
|
| Rate for Payer: HFN Commercial |
$2,757.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,247.75
|
| Rate for Payer: Multiplan Commercial |
$2,397.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,798.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,757.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,468.53
|
| Rate for Payer: Quartz Commercial |
$1,948.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,798.20
|
| Rate for Payer: The Alliance Commercial |
$11,988.00
|
| Rate for Payer: WEA Trust Commercial |
$1,648.35
|
| Rate for Payer: WPS Commercial |
$2,219.88
|
|
|
INSTRUMENTS RTS LESSER MTP M04 S0001
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6021651
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,566.53 |
| Max. Negotiated Rate |
$2,941.24 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$1,918.20
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
INSTRUMENTS RTS LESSER MTP M04 S0001
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6021651
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$895.16 |
| Max. Negotiated Rate |
$12,788.00 |
| Rate for Payer: Aetna Commercial |
$2,877.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.42
|
| Rate for Payer: Aetna Managed Medicare |
$895.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.41
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$2,941.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.04
|
| Rate for Payer: Health EOS Commercial |
$2,845.33
|
| Rate for Payer: HFN Commercial |
$2,941.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.75
|
| Rate for Payer: Multiplan Commercial |
$2,557.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.53
|
| Rate for Payer: Quartz Commercial |
$2,078.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.20
|
| Rate for Payer: The Alliance Commercial |
$12,788.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.35
|
| Rate for Payer: WPS Commercial |
$2,368.02
|
|
|
INSTRUMENTS RTS SZ 1-2 M03 S0002
|
Facility
|
IP
|
$3,885.00
|
|
| Hospital Charge Code |
6131658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,903.65 |
| Max. Negotiated Rate |
$3,574.20 |
| Rate for Payer: Aetna Commercial |
$3,496.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,341.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,059.05
|
| Rate for Payer: Cash Price |
$1,165.50
|
| Rate for Payer: Cigna Commercial |
$3,574.20
|
| Rate for Payer: Health EOS Commercial |
$3,457.65
|
| Rate for Payer: HFN Commercial |
$3,574.20
|
| Rate for Payer: Multiplan Commercial |
$3,108.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,331.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,574.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,903.65
|
| Rate for Payer: Quartz Commercial |
$2,331.00
|
| Rate for Payer: WEA Trust Commercial |
$2,136.75
|
| Rate for Payer: WPS Commercial |
$2,877.62
|
|
|
INSTRUMENTS RTS SZ 1-2 M03 S0002
|
Facility
|
OP
|
$3,885.00
|
|
| Hospital Charge Code |
6131658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,087.80 |
| Max. Negotiated Rate |
$15,540.00 |
| Rate for Payer: Aetna Commercial |
$3,496.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,341.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,087.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,525.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,942.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,864.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,059.05
|
| Rate for Payer: Cash Price |
$1,165.50
|
| Rate for Payer: Cigna Commercial |
$3,574.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,174.05
|
| Rate for Payer: Health EOS Commercial |
$3,457.65
|
| Rate for Payer: HFN Commercial |
$3,574.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,913.75
|
| Rate for Payer: Multiplan Commercial |
$3,108.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,331.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,574.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,903.65
|
| Rate for Payer: Quartz Commercial |
$2,525.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,331.00
|
| Rate for Payer: The Alliance Commercial |
$15,540.00
|
| Rate for Payer: WEA Trust Commercial |
$2,136.75
|
| Rate for Payer: WPS Commercial |
$2,877.62
|
|
|
Insulin Antibody
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
977996
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$384.56 |
| Rate for Payer: Aetna Commercial |
$376.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.48
|
| Rate for Payer: Aetna Managed Medicare |
$21.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.54
|
| Rate for Payer: Anthem Medicaid |
$22.12
|
| Rate for Payer: Anthem Medicare Advantage |
$21.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.41
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$384.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.91
|
| Rate for Payer: Dean Health Medicaid |
$22.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.41
|
| Rate for Payer: Health EOS Commercial |
$372.02
|
| Rate for Payer: HFN Commercial |
$384.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.41
|
| Rate for Payer: Managed Health Services Medicaid |
$23.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.41
|
| Rate for Payer: Multiplan Commercial |
$334.40
|
| Rate for Payer: NAPHCARE Commercial |
$32.12
|
| Rate for Payer: Preferred Network Access Commercial |
$384.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22.12
|
| Rate for Payer: Quartz Beloit One Network |
$204.82
|
| Rate for Payer: Quartz Commercial |
$271.70
|
| Rate for Payer: Quartz Medicare Advantage |
$21.41
|
| Rate for Payer: The Alliance Commercial |
$85.64
|
| Rate for Payer: United Healthcare Medicaid |
$22.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.41
|
| Rate for Payer: United Healthcare PPO |
$313.50
|
| Rate for Payer: WEA Trust Commercial |
$229.90
|
| Rate for Payer: Wellcare Medicare |
$21.41
|
| Rate for Payer: WMAP Medicaid |
$22.12
|
| Rate for Payer: WPS Commercial |
$309.61
|
|
|
Insulin Antibody
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
977996
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$204.82 |
| Max. Negotiated Rate |
$384.56 |
| Rate for Payer: Aetna Commercial |
$376.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.54
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$384.56
|
| Rate for Payer: Health EOS Commercial |
$372.02
|
| Rate for Payer: HFN Commercial |
$384.56
|
| Rate for Payer: Multiplan Commercial |
$334.40
|
| Rate for Payer: NAPHCARE Commercial |
$250.80
|
| Rate for Payer: Preferred Network Access Commercial |
$384.56
|
| Rate for Payer: Quartz Beloit One Network |
$204.82
|
| Rate for Payer: Quartz Commercial |
$250.80
|
| Rate for Payer: WEA Trust Commercial |
$229.90
|
| Rate for Payer: WPS Commercial |
$309.61
|
|
|
Insulin Antibody
|
Professional
|
Both
|
$418.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
977996
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.58 |
| Max. Negotiated Rate |
$397.10 |
| Rate for Payer: Aetna Commercial |
$397.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.48
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$397.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$209.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.80
|
| Rate for Payer: Health EOS Commercial |
$380.38
|
| Rate for Payer: HFN Commercial |
$397.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.58
|
| Rate for Payer: Multiplan Commercial |
$334.40
|
| Rate for Payer: Preferred Network Access Commercial |
$397.10
|
| Rate for Payer: Quartz Beloit One Network |
$183.92
|
| Rate for Payer: Quartz Commercial |
$238.26
|
| Rate for Payer: The Alliance Commercial |
$209.00
|
| Rate for Payer: WEA Trust Commercial |
$229.90
|
| Rate for Payer: WPS Commercial |
$309.61
|
|
|
Insulin Injection J1815
|
Professional
|
Both
|
$6.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4017969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.60
|
| Rate for Payer: Health EOS Commercial |
$5.46
|
| Rate for Payer: HFN Commercial |
$5.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5.70
|
| Rate for Payer: Quartz Beloit One Network |
$2.64
|
| Rate for Payer: Quartz Commercial |
$3.42
|
| Rate for Payer: The Alliance Commercial |
$3.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.90
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
